IMMUNIZATION & PHYSICAL FORM CELOP

Transcription

1 Boston University Student Health Services 881 Commonwealth Ave 1 st floor WEST Boston, MA Phone: (617) IMMUNIZATION & PHYSICAL FM CELOP BU Student ID #: Necessary for all students U PLEASE UPLOAD ONLINE ON OUR HEALTH PTAL PATIENT CONNECT bu.edu/patientconnect FM IS DUE PRI TO MATRICUATION. WE CANNOT ACCEPT ANY MEDICAL DOCUMENTS VIA . PART 1: COMPLETED BY THE STUDENT ALL INFMATION MUST BE PRINTED LEGIBLY FM CANNOT BE PROCESSED Last Name: First Name: Middle : DOB (mm/dd/yy): Date of Entry to BU (month/year): Active Address: Please Check: University Housing Commuter School, College, or Program at BU: EOP Please Check: Undergraduate Graduate Clinical/Medical Student s Cell Phone #: Carrier: For comprehensive information about Student Health Services, including hours and directions, please visit: PART 2: REQUIRED IMMUNIZATIONS PRI TO ARRIVAL AT BU VERIFIED AND SIGNED BY HEALTH CARE PROVIDER (MD/NP/PA) A. MMR (Measles, Mumps, Rubella) Two doses of MMR vaccine (after 1 st birthday), two doses of each individual component, positive titers. MMR Vaccination #1 (oldest): MUST BE GIVEN AFTER 1st BIRTHDAY MMR Vaccination #2 (newest): Minimum of 4 weeks after 1 st dose Measles Vaccination: #1 #2 Mumps Vaccination: #1 #2 Rubella Vaccination: #1 #2 Positive Titers: Measles Titer Mumps Titer Rubella Titer B. Tdap (Tetanus, Diphtheria, & Pertussis) Must be within the past 10 years. No other form of the Tetanus shot is acceptable. Tdap Vaccination: (Td shot is not acceptable, must be Tdap) *If not available in your country, leave blank and receive at SHS

2 C. Meningitis One dose within 5 years for all students living on campus required or a completed waiver. A dose after age 16 is recommended for maximal protection. Meningitis Vaccination: Menactra Menomune MENINGITIS WAIVER Meningococcal Waiver is ONLY if you plan on waiving the requirement for the Meningococcal Vaccine. If you have received the vaccine, please ignore this waiver. Waiver for Meningococcal Vaccination Requirement I have reviewed the Meningococcal Information section of the SHS Immunization page: Check below: After reviewing the materials above on the dangers of meningococcal disease, I choose to waive receipt of the meningococcal vaccine. Student Signature: Date: (Parent/Guardian signature if student is under 18 years old) D. Hepatitis B Completed 3 part series required or proof of a positive titer. Hep B Vaccination #1 (oldest) Hep B Vaccination #2 Hep B Vaccination #3 (newest) Hepatitis B Positive Titer: E. Varicella Two doses required, or proof of a positive titer, or a history of the disease verified by your health care provider. Varicella Vaccination #1 (oldest): Varicella Vaccination #2 (newest): Varicella Positive Titer: Date of Disease: Must include the month, date, and year to be accepted. Clinician s Name, MD/NP/PA (please print) Signature Date BU ID #

3 PART 3: REQUIRED TUBERCULOSIS(TB) HISTY PRI TO ARRIVAL AT BU COMPLETED BY STUDENT AND SIGNED BY HEALTH CARE PROVIDER (MD/NP/PA) A. General Tuberculosis History Have you had a positive tuberculosis skin test in the past? YES (Complete Section B) NO (Complete Section C) B. Positive Tuberculosis & Evaluation/Treatment History Positive Skin Test: Plant Date / / Plant Read / / Result in MM: Blood QuantiFERON Gold Test: / / Result: Positive Negative Have you ever had a BCG Vaccine? No / Yes If yes, what was the date of the vaccine? / / Chest X Ray Date: / / Result: Normal Abnormal (describe) Clinical Evaluation Date: / / (Must be within 1 year of matriculation) Normal (Absence of cough, hemoptysis, fevers, chills, sweats, weight loss) Abnormal (describe): Treatment Date Range: / / Yes (Drug, dose, frequency) No (Please document the reason prophylaxis or treatment was not done): C. Negative Tuberculosis History 1. Are you an international student? YES NO 2. To the best of your knowledge, have you had close contact with anyone YES NO who was sick with tuberculosis? 3. Were you born in or have you travelled for extended periods of time YES NO (more than 1 month) to one of the high risk countries found here: 4. Have you completed 6 9 months of medication to prevent active tuberculosis? YES NO (i.e. isoniazid) If you answered YES to any of the previous questions (1 4) you must provide proof of a recent tuberculosis test administered within the last year in the table below: Tuberculosis Skin Test (Must be within the past year) QuantiFERON Gold Test Plant Date / / Date / / Read Date (within hours of plant) / / Result Positive Negative MM Clinician s Name, MD/NP/PA (please print) Signature Date BU ID #

4 PART 4: OPTIONAL IMMUNIZATIONS PRI TO ARRIVAL AT BU VERIFIED AND SIGNED BY HEALTH CARE PROVIDER (MD/NP/PA) A. Influenza One dose of vaccination every year is highly recommended. Influenza Vaccination (most recent): B. Polio Those traveling to areas where polio is common should consider an additional 1 2 doses of vaccine. Polio Vaccination #1 (oldest): Polio Vaccination #2 (newest): C. Hepatitis A Two vaccinations should be given 6 months apart from one another. Hepatitis A Vaccination #1 (oldest): D. Typhoid The injection lasts for 2 years. The oral vaccine lasts for 5 years. Hepatitis A Vaccination #2 (newest): Typhoid Injection: E. Yellow Fever One vaccination lasts for 10 years. Typhoid Oral Vaccination: Yellow Fever Vaccination: F. TwinRix (Combination of Hep A and Hep B) Three doses given over the course of 6 months. TwinRix Vaccination #1 (oldest): TwinRix Vaccination #2: PART 5: RECOMMENDED PHYSICAL INFMATION TwinRix Vaccination #3 (newest): G. HPV (Human Papilloma Virus) 1 st dose to be followed by 2 nd dose after two months, followed by 3 rd dose six months after 1 st dose. HPV Vaccination #1 (oldest): HPV Vaccination #2: HPV Vaccination #3 (newest): VERIFIED AND SIGNED BY MD/NP/PA **This form may be submitted without a physical Date of physical exam (must be within 1 year of matriculation): MM / DD / YYYY *NCAA Varsity Athletes: Per NCAA Bylaw : Within six months prior to participation in any practice, competition or out of season conditioning activities, student athletes shall be required to undergo a medical examination or evaluation administered by a physician. This student has been evaluated to be in good health and is able to participate in highly competitive athletics, if they choose to do so: YES / NO (If no, please explain): Clinician s Name, MD/NP/PA (please print) Signature Date BU ID #

5 REQUIRED HEALTH HISTY Must be signed by MD/NP/PA 1. List any significant past medical, surgical or mental health conditions including hospitalizations. Use additional pages if necessary. None 2. List all ongoing medications or treatments with dosages/directions and briefly describe what each medication is treating None Medication, dose, directions Condition addressed by this medication 3. List all environmental or medical allergies. None 4. Note any pertinent family history. None 5. List all pertinent physical exam findings. PE within normal limits Abnormal findings as follows Clinician s Name, MD/NP/PA (please print) Signature Date BU ID #

6 REQUIRED STUDENT INFMATION (To be completed by the student) We at Student Health Services recognize that this time in your life can be both exciting and stressful. We want to be sure you know that free evaluations, short term counseling and medication management are available in our Behavioral Medicine Department. If you find that you are feeling anxious, depressed or overwhelmed with new experiences that college has to offer, please call or stop by to access our confidential services. The following are some questions about your emotional and mental health. The responses are completely confidential and are solely for the purpose of providing excellent service to students. You may opt not to answer the questions. 1. Have you ever been on medications for a mental health problem including depression, anxiety, bipolar disorder or other psychological disorders? Yes No 2. Have you ever been hospitalized for a mental health problem, including an eating disorder or substance abuse? Yes No 3. If yes to any of the above questions, would you like to be contacted by a Behavioral Medicine provider? Yes No Mental Health Resources Boston University Student Health Services Behavioral Medicine Department (617) The Danielsen Institute (617) The Center for Anxiety and Related Disorders (617) The Center for Psychiatric Rehabilitation (617) Please visit our mental health resources website at Students with Disabilities Students with a disability of any kind may request accommodations through the Office of Disability Services. Since it may take some time for this process, please check the website and/or contact the Office of Disability Services as soon as possible: (617) For students with ADD/HD who will require prescription medication, we require a report of psychological testing confirming this diagnosis from within the prior three years. If you are in need of testing and wish to have it when you come to Boston University, please call Behavioral Medicine at (617) for information on beginning this process.

7 REQUIRED CONSENTS AND ACKNOWLEDGMENTS I hereby authorize the clinical staff at Boston University Student Health Services to examine and treat me during my enrollment at Boston University. I understand that there is no charge to see a provider at Boston University Student Health Services. However, I understand that I am responsible for miscellaneous charges including, but not limited to, lab tests, allergy injections, immunizations, and some supplies. I understand that I am responsible for all health care charges outside of Student Health Services except that which is covered by my health insurance. I understand that some costs outside of Student Health Services may not be covered by my medical insurance. I understand that Student Health Services is a unit inclusive of medical, mental health, nutrition, sports medicine, and alcohol and other drug services. I understand that the providers within this organization may discuss my care within the unit to allow for effective care delivery and care management. I understand that some services provided are limited by staff and space availability. While we may endeavor to serve all students eligible for care, there may be circumstances when referral to outside providers in the community is necessary. The information on this form is for the use of Student Health Services and will not be released to a third party without your consent, except as necessary to fulfill the responsibilities of Student Health Services or as required by law. Student Name (Print) Student Signature Date (Must be signed by a parent or guardian if student is under 18 years of age)

8 YOU MUST FOLLOW THESE STEPS AND UPLOAD YOUR FM(S) TO BOSTON UNIVERSITY STUDENT HEALTH SERVICES BEFE CLASSES BEGIN. Download and Complete the Health Requirement Form(s) 1. Please complete and sign your Immunization and Physical Form in English. If you are under the age of 18, you must complete the Minor Authorization Form. 2. When your form(s) is complete, please follow these steps to upload your form(s) to our secure online health portal Patient Connect. Forms are located at: CELOP Upload and Submit Form(s) 1. Take a picture of your completed forms or scan them to your computer. There should be one picture for each page that has been filled out. If you have questions, please contact CELOP Admissions (celop@bu.edu). 2. Go to in your web browser, select Secure Login.

9 3. Log into Patient Connect using your BU Kerberos account issued by the university and then verify your date of birth. 4. Once logged in, click on the word Forms from the menu bar and click on Immunization and Physical Form Upload.

10 5. Click on the button Add Immunization record and attach the images of your Immunization and Physical Form that you took on your phone or scanned on your computer. 6. Once all of your records have been updated, click on the word Submit Final in the blue box. Important Reminders 1. Forms must be filled out in English. 2. Forms should be signed and stamped by Health Care provider (not parents/guardian). 3. Forms should be uploaded to PatientConnect. 4. If you are unable to receive certain immunizations in your home country prior to arriving to the U.S. and your form is incomplete, please still submit your form and you will be able to receive them in Boston. 5. If you are enrolled in BU s Student Health Insurance Plan (SHIP), all immunizations are covered only if received at BU Student Health Services. 6. Students not enrolled in BU s Student Health Insurance Plan (SHIP) can still receive immunizations at BU Student Health Services, but will be charged on their Student Account. Please visit for more information regarding SHIP. If you have any other questions, please visit for more information or CELOP Admissions at celop@bu.edu.